Endocrinology Flashcards
Causes of hyponatraemia with >20mmol urinary sodium
Addison’s
Diuretics
Renal failure
Euvolaemic - hypothyroidism, SIADH
Prolactinoma treatment
Dopamine agonists (cabergoline, bromocriptine)
Trans-sphenoidal surgery
Prolactinoma symptoms?
Amenorrhoea, galactorrhoea, impotence, osteoporosis (women), loss of libido
What does a a dexamethasone test entail and what is it used for?
Suspected Cushing’s
Low dose 1mg, high dose 8mg
What does a low cortisol following high dose dexamethasone suggest?
Cushing’s Disease (i.e. pituitary adenoma)
What does a high/normal cortisol following high dose dexamethasone suggest?
High ACTH: ectopic ACTH (small cell lung carcinoma)
Low ACTH: Cushing’s Disease
What are the ACTH dependent and ACTH independent causes of Cushing’s?
Dependent: Pituitary adenoma (Cushing’s disease), ectopic ACTH (small cell carcinoma)
Independent: iatrogenic steroids, adrenal adenoma
What are two syndromes associated with hypothyroidism?
Down’s
Turner’s
Causes of primary hypothyroidism
Hashimoto's hypothyroidism Subacute thyroiditis (De Quervain's) Riedel thyroiditis Post-thyroidectomy or radioiodine treatment Drug therapy e.g. lithium, carbimazole) Dietary iodine deficiency
What are Sertoli cells stimulated by and what do they produce?
Stimulated by FSH
Produce sperm and jnhibins A and B
What are Leydig cells stimulated by and what do they produce?
Stimulated by LH
Produce testosterone
What is the role of Inhibin
Negative feedback on pituitary to decrease FSH
What is the role of FSH and LH in the female?
LH stimulates theca cells to produce androgens
FSH stimulates follicular development and oestrogen production (from androgens) in granulosa cells
When does puberty in boys start and finish?
10-14
15-17
What antibodies are seen in Hashimoto’s?
Anti-TPO
35-year-old woman is found to have a blood pressure of 180/110 mmHg. She complains of feeling tired and weak. Routine bloods show hypokalaemia
Primary hyperaldosteronism
40-year-old woman presents with lethargy, weakness and weight loss. On examination her blood pressure is 80/50 mmHg and there is hyperpigmentation of the skin
Addison’s
Features of primary hyperaldosteronism
Tiredness
Hypertension (due to resorption of sodium)
Hypokalaemia - muscle weakness
Alkalosis
Primary hyperaldosteronism investigations and management
Aldosterone/renin ratio - raised aldosterone, low renin (negative feedback from retained sodium)
CT scan and Adrenal Venous Sampling (AVS) - uni or bilateral
Adrenal adenoma - surgery
Bilateral adrenocortical hyperplasia - aldosterone antagonist (spironolactone)
A 60-year-old woman is investigated for heat intolerance and weight loss. The free T4 level is elevated and the TSH is suppressed. Nuclear scintigraphy reveals an enlarged thyroid gland with patchy uptake. Diagnosis?
Toxic multinodular goitre
What antibodies are present in Grave’s disease?
TSH receptor antibodies
What electrolyte imbalance can sarcoidosis cause?
Hypercalcaemia
What is the action of SGLT-2 inhibitors?
Inhibits reabsorption of glucose in the kidney
Risk of weight loss, genital infections and DKA (increases glucose secretion by kidneys)
Don’t give in thrush patients!
Action of metformin?
Increases insulin sensitivity
Decreases hepatic gluconeogenesis
Characteristics of sick euthyroid syndrome?
Systemic illness
Inappropriately normal TSH with low T3
Returns to normal when recovers from underlying illness
What are the endocrine side effects of corticosteroids?
Impaired glucose control (anti-insulin effect) Weight gain and appetite Hirsutism Hyperlipidaemia Cushing's syndrome
What are the non-endocrine side effects of corticosteroids?
Glucocorticoids Avascular necrosis of the femoral head Psych: depression, mania, insomnia, psychosis Immunosuppression GI: peptic ulceration, acute pancreatitis Eyes: glaucoma, cataracts Intracranial hypertension Neutrophilia Osteoporosis Growth suppression in children
Mineralcorticoids
Hypertension
Fluid retention
What is the action of sulfonylureas and who should they be avoided in?
Increases insulin secretion by beta cells
Avoid if pregnant or breastfeeding or at risk of hypoglycaemia
What condition is associated with initial few weeks painful goitre, ESR and hyperthyroidism followed by hypothyroidism and raised ESR? And what is management?
Subacute thyroiditis (de Quervain’s)
Self-limiting (steroids if severe)
Side effects of metformin (biguanides)?
GI upset, lactic acidosis in those with renal failure
Primary hyperparathyroidism characteristics
Elderly lady with: Renal stones Bone pain Peptic ulceration/constipation Renal stones Depression Polydipsia, polyuria
Associated with:
HTN
MEN I and II
Addison’s characteristics
Lethargy, weakness, anorexia, nausea, vomiting, abdominal pain, salt craving, muscle wasting
Hyperpigmentation of palmar creases and mucous membranes, vitiligo, loss of pubic hair
Hyperkalaemia, hyponatraemia, hypoglycaemia, hypotension
Toxic multinodular goitre characteristics and management
Autonomously functioning nodules in thyroid resulting in hyperthyroidism
Patchy uptake with nuclear scintigraphy
Radioiodine therapy
Thyrotoxicosis treatment
Propanalol for symptom management
Carbimazole (reduces thyroid hormone production) - agranulocytosis risk
Radioiodine treatment
What drug can cause thyrotoxicosis?
Amiodarone
40-year-old patient with a history of hypertension presents with episodic palpitations, excessive sweating, headaches and tremor
Pheochromocytoma
What is pheochromocytoma?
Catecholamine secreting tumour associated with MEN II and neurofibromatosis
Hypertension, palpitations, sweating, headaches, anxiety
Investigation and management of pheochromocytoma
24 hr urinary collection of metanephrines
Alpha blocker (phenoxybenzamine) Beta blocker (propanalol) Surgery 10 days later to remove tumour
Pioglitazone side effects
Weight gain Fluid retention (DONT GIVE IN HEART FAILURE) Liver impairment (monitor LFTs) Risk of bladder cancer Risk of fractures
Action and side effects of GLP-1 agonists (-tides)
Incretin mimetic which inhibits glucagon secretion and enhance glucose-dependent insulin secretion
SEs: Nausea, vomiting, weight loss and pancreatitis
A patient presents with muscle cramping and perioral paraesthesia two months after having thyroid surgery - primary hypoparathyroidism
Primary hypoparathyroidism
Treatment of hypoparathyroidism
Alfacalidol
MEN I features
Peptic ulceration, hypercalcaemia, galactorrhoea
MEN I endocrine organs?
3 Ps
Pituitary
Pancreas (Zollinger Ellison - ulcers/gastric acid; insulinoma)
Parathyroid
(also adrenal and thyroid)
2-month-old baby is noted to have hypotonia, macroglossia and a puffy face. They were treated at birth for neonatal jaundice
Congenital hypothyroidism
newborn baby is noted to have ambiguous genitalia. At 2 weeks they develop severe vomiting, dehydration and weight loss
Congenital adrenal hyperplasia
Klinefelter’s syndrome characteristics
Small, firm testes Raised gonadotrophin levels, but low testosterone Above average height Ambiguous secondary characteristics Infertile Gynaecomastia
Dx by karyotype testing (karyotype 47 XXY)
hypokalaemia, hypertension, alkalosis, no similar family history, raised aldosterone
Conn’s Syndrome
a baby is born with ambiguous genitalia, exhibiting labioscrotal folds with clitoromegaly. At 13 years of age the child undergoes virilization with facial hair and deepening of the voice
5-alpha reductase deficiency
tall, slim 18-year-old man presents with hypogonadism. He also complains of anosmia. Gonadotrophin levels are reduced
Kallman’s Syndrome
Features of congenital hypothyroidism
Prolonged neonatal jaundice Delayed mental and physical milestones Puffy face Macroglossia Hypotonia Short stature
hypokalaemia, hypertension, alkalosis, family history of similar problems, low aldosterone
Liddle’s syndrome
Conn’s syndrome features
No family hx Hypokalaemia Hypertension Alkalosis Raised aldosterone
De Quervain’s/subacute thyroiditis phases
Phase 1 (3-6 weeks): thyrotoxicosis, raised ESR, painful goitre (viral illness)
Phase 2 (weeks): euthyroid
Phase 3 (months): hypothyroidism
Phase 4: back to normal
What effect does cortisol have on kidneys and electrolytes?
Increases water and sodium retention
Increases potassium excretion
Hypokalaemic metabolic alkalosis
Myxoedema coma features
Confusion and fatigue Hypothermia Ankle swelling Reduced respiratory rate and HR Initial diastolic HTN followed by hypotension Hair thinning Cool dry skin
Myxoedema coma precipitating factors and treatment
Viral illness
Amiodarone
Beta blockers
Surgery, stroke, trauma
Tx: IV thyroid replacement, steroids, fluid
Correct electrolyte imbalances
Thyroid cancer with worst prognosis
Anaplastic (elderly patients)
Most common thyroid cancer and characteristics
Papillary
Young females, cervical lymph node mets
Thyroglobulin used as tumour marker
Characteristic Orphan Annie eyes on light microscopy
Follicular thyroid cancer characteristics
> 50 females
Lung and bone mets
Thyroglobulin used as tumour marker
Usually solitary nodule
Addison’s treatment
Hydrocortisone (glucocorticoid): 15-30mg in divided doses (should follow work pattern for shift workers)
Fludrocortisone (mineralocorticoid): 50-300mcg (adjusted to exercise levels and metabolism)
MedicAlert bracelet and steroid card
Double hydrocortisone during illnesses
T1 diabetic blood glucose targets
4-7mmol/L before meals
5-7mmol/L on waking
Addisonian crisis causes, features and treatment
Sepsis or surgery; infection in Addison patient; adrenal haemorrhage; abrupt withdrawal of steroids (most common)
Confusion with - hyponatraemia, hypotension, hypoglycaemia, hyperkalaemia, dehydration
100mg IV hydrocortisone and 1L saline (with dextrose if hypoglycaemic).
Continue hydrocortisone 6 hourly until stable. Oral replacement after 24 hours.
Monitor electrolytes
Fludrocortisone added for long–term management
Causes of Addison’s
Autoimmune adrenalitis (developed countries)
TB (worldwide)
Metastises
Amyloidosis
Causes and features of DKA
Causes: missed insulin, infection, MI
Features: vomiting, abdominal pain, polyuria, polydipsia, dehydration, Kussmaul breathing, acetone breath smell
Diagnostic criteria for DKA
Blood glucose >11mmol/L or known DM
pH <7.3
Bicarbonate <15mmol/L
Ketones >3mmol/L or ++ on urine
Initial DKA management
1L normal saline over an hour (add potassium for following hours)
Insulin: O.1ml/kg/hour - when BM <15mmol/L then start 5% dextrose
Long-acting insulin continued
What are young DKA patients at risk of with treatment, what are the features and how should you adapt?
Risk of cerebral oedema - headache, irritability, visual disturbance, focal neuropathy
Give slower infusion
CT scan if suspected
When should you replace potassium in DKA?
<5.5mmol/L
Complications of DKA and its treatment
Gastric stasis
AKI
Arrhythmias secondary to hyperkalaemia/hypokalaemia
Incorrect fluid management leading to hypokalaemia, hypoglycaemia or cerebral oedema
ARDS
What characteristics would you see in someone with congenital adrenal hyperplasia?
Early menarche, hirsutism, large stature (virilization - in response to low cortisol pituitary produces raised levels ACTH, leading to increased adrenal androgen production)
Low cortisol, low sodium, raised potassium
What is the commonest cause of congenital adrenal hyperplasia?
Deficiency of 21-hydroxylase enzyme (responsible for aldosterone and cortisol synthesis)
How often should HbA1C be monitored in T1 diabetics and what should the target be?
Every 3-6 months
Below 48mmol/mol
How often should a T1 diabetic with well-controlled BM be monitoring blood glucose?
4 times a day including before each meal and before bed
Increase during illness, if hypoglycaemic episodes increase, when planning pregnancy, during pregnancy and breastfeeding
Diagnosis of T2 diabetes?
Random glucose >11.1mmol/mol
Fasting glucose >7mmol/mol
HbA1C >48mmol/L (if symptomatic)
If asymptomatic need 2 readings
Indications for prescribing growth hormone therapy?
Prader-Willi syndrome
Turner Syndrome
Chronic renal insufficiency before puberty
Proven growth hormone deficiency
Adverse effects of growth hormone therapy
Headaches
Benign intracranial hypertension
Fluid retention
Turner syndrome signs and symptoms
PRIMARY AMENORRHOEA (fibrosed ovaries) HYPOTHYROIDISM (and other AI conditions) Bicuspid aortic valve or coarctation of the aorta Webbed neck Lymphoedema in neonates Low set ears Wide spaced nipples Horseshoe kidney
Test to differentiate between T1 and T2 diabetes
C-peptide (low in T1 as pancreas not making enough insulin precursor which breaks down into C-peptide and insulin; normal/high in T2)
Advice for T1 diabetics during illness?
Monitor blood glucose more frequently
Continue same insulin doses
Monitor urinary ketones every 4 hours
What type of drug is sitagliptin and when would you add it to a regimen?
DDP-4 inhibitor (doesn’t cause weight gain)
If a thiazolidinedione is contraindicated due to weight or poor response
What is GLP-1?
Glucagon-like peptide 1, produced by the small intestine in response to raised glucose levels
GLP-1 is an analogue
DDP-4 inhibits its breakdown
Give an example of a GLP-1 and its adverse effects
Exenatide
Nausea and vomiting
Causes weight loss
Hyperosmolar Hyperglycaemic State characteristics
T2 diabetic
General: lethargy, vomiting, recurrent infections
Neurological: headaches, papilloedema, reduced consciousness, weakness
CV: dehydration, hypotension, tachycardia
HHS diagnosis
Raised blood glucose >30mmol/mol Mild ketonaemia (<3mmol/mol) Hypovolaemia Raised serum osmolarity pH >7.3 (less acidotic than DKA)
HHS management
0.9% saline to reduce osmolality and replace fluids (use 0.45% if osmolarity not restoring)
Monitor osmolarity, sodium and glucose on a graph
Target glucose: 10-15mmol/mol
When should you give insulin to HHS patient?
ONLY if significant ketonaemia
What is the inheritance pattern of maturity onset diabetes of the young?
Autosomal dominant
Characteristics of MODY
<25
Family history
Ketosis rare
Sensitivity to sulfonylureas (insulin rarely needed)
What condition would give a lower than expected HbA1C?
Sickle Cell Anaemia due to reduced RBC lifespan
What conditions would give a higher than expected HbA1C? (due to increased RBC lifespan)
Vitamin B12/folic acid deficiency
Splenectomy
Iron-deficiency anaemia
Alcoholism
Main carbimazole side effect
Agranulocytosis
Management of Graves’
Anti-thyroid (carbimazole) followed by thyroxine when euthyroid
Radioiodine treatment
Propanalol to block adrenergic effects
Radioiodine treatment contraindications and side effects
Pregnancy (don’t get pregnant at least 4-6 months after treatment)
Thyroid eye disease (precipitates)
Side effects: thyroid eye disease, hypothyroidism
Common non-diabetic causes of hypoglycaemia
EXogenous drugs (alcohol, quinine, ACE-i) Pituitary insufficiency Liver failure Addison's disease Islet cell tumours (insulinoma) Non-pancreatic neoplasms
Management of subclinical hypothyroidism
> 65 - watchful waiting
<65 and symptomatic - start trial of levothyroxine
If >10mU/L of TSH and asymptomatic - start levothyroxine (unless elderly)
Asymptomatic - repeat TFTs in 6 months
Definition of subclinical hypothyroidism
raised TSH, normal T3 and T4
Asymptomatic
What are the main effects of a pituitary adenoma?
Excess of hormones (e.g. Cushing’s disease, acromegaly or excess prolactin)
Depletion of hormones due to compression of pituitary
Stretching of dura (headaches)
Compression of optic chiasm (bitemporal hemianopia)
Investigations for pituitary adenomas
Pituitary blood profiles: GH, ACTH, prolactin, FSH, LH, TFTs
Formal visual fields
MRI brain
What is CA 19-9 a marker for?
Pancreatic cancer
What hormone do medullary cancers usually produce?
Calcitonin
What is gliclazide and what side effects are there?
Sulfonylurea
Weight gain and hypoglycaemia
Management of thyroid patient with visual changes?
Urgent specialist review (especially loss of colour vision)
Type 1 diabetic with bloating, vomiting, and impaired glucose control - diagnosis and management
Gastroparesis (neuropathy of vagus nerve)
Mx: Metoclopramide or erythromycin
What is Whipple’s triad and what does it diagnose?
Symptoms and signs of hypoglycaemia
Hypoglycaemia (<2.5mmol/L)
Reversibility of symptoms on administration of glucose
INSULINOMA
C-peptide levels do not fall on insulin administration (endogenous levels are not reduced)
Effect of insulin
Causes liver, skeletal muscle and fat cells to absorb glucose
Liver and skeletal muscle: glycogen
Fat cells: triglycerides
Causes of raised prolactin
Pregnancy Prolactinoma Physiological PSCOS Primary hypothyroidism Phenothiazines, metocloPramide, domPeridone
High calcium, high or inappropriately normal PTH
Primary hyperparathyroidism
Cause of secondary hyperparathyroidism
Chronic hypocalcaemia e.g. CKD
Low or normal calcium and high PTH
Cause of tertiary hyperparathyroidism
Secondary hyperparathyroidism resulting in autonomous PTH secretion (end-stage renal disease patients)
high PTH
Mildly raised calcium
What should T2 diabetics be given when started on insulin
Glucagon kit for hypos
Also should have sweets or juices ready
Most common presentation of MEN I
Hypercalcaemia
MEN IIa and b associations
Medullary thyroid cancer, phaeochromocytoma and RET oncogene
IIa: hyperparathyroid
IIb: marfanoid body habitus, neuromas
T2 diabetic on lifestyle changes target glucose
48
T2 diabetic with lifestyle and metformin target
48
T2 diabetic on one drug but HbA1C increased to >58 - whats the target?
53
What is the gene in MEN I
MEN gene
How can you distinguish between an insulinoma and someone injecting insulin?
Insulinoma: high c-peptide
Exogenous insulin: low/normal c-peptide
What are the DVLA restrictions for a diabetic on insulin who wants an HGV license?
No severe hypoglycaemic episodes in past 12 months
Full hypoglycaemic awareness
Good glucose control, with twice daily monitoring and at times relevant to driving
No other debarring complications
Klinefelter’s syndrome blood results
High gonadotrophins (FSH/LH)
Low testosterone
PRIMARY HYPOGONADISM
What is the CT head finding on the skull with hyperparathyroidism?
Pepper pot skull
What is the purpose of Kussmaul breathing
Deep and laboured to expel excess CO2 with metabolic acidosis
DKA blood results
Hyponatraemia
Low bicarbonate
Normal-high potassium (although insulin therapy can cause hypokalaemia and arrhythmias)
What is Zollinger-Ellison Syndrome and when might you see it?
Gastrin-secreting tumour in the islet cells of the pancreas or duodenal wall leading increased HCl production gastric antrum. This results in duodenal ulcers.
Seen in MENI
Insulin side effects
Weight gain, lipodystrophy, hypoglycaemia
Name an aldosterone antagonist given to someone with bilateral adrenal hyperplasia
Spironolactone
What is the primary action of orlistat?
Pancreatic lipase inhibitor (decreases breakdown and absorption of lipids)
Side effects of thyroxine treatment
Hyperthyroidism
Reduced bone mineral density
Exacerbation of angina
AF
T2 BP targets (end organ and no end organ damage)
No end organ damage: <140/80
End organ damage: <130/80
What is Trosseau’s sign?
Hypocalcaemic patient
On inflation of BP cuff past systolic, wrist flexes and fingers adduct
OGTT at 2 hours for impaired glucose tolerance?
7.8-11.1 mmol/mol
How do thyroid problems affect periods?
Hyperthyroidism: amenorrhoea or oligomenorrhoea
Hypo: menorrhagia
Most common cause of primary hyperparathyroidism?
Solitary parathyroid adenoma
What can ACTH be cleaved into, and what does that then effect?
melanocyte stimulating hormone resulting in hyperpigmentation (especially of oral mucosa and palmar creases)
Highest and lowest points of cortisol levels?
Highest: 8am
Lowest: midnight/1am
What causes an increase in renin levels?
Renal artery hypotension
Sympathetic nervous stimulation
Reduce sodium levels in distal tubule
What is renin’s action?
Cleaves angiotensinogen into angiotensin I
Role of ACE and where is it found?
Converts angiotensin I into angiontensin II
Found in vascular epithelium of the lung
Angiotensin II function?
Stimulates ADH release
Sodium reabsorption
Aldosterone (mineralcorticoid) release
Vasoconstriction
What is aldosterone released in response to, and what are its effects?
Release due to: angiotensin II, ACTH, potassium levels
Effects: increases number of epithelial sodium channels in distal tubule - sodium and water reabsorption, potassium excretion
Causes of adrenal insufficiency?
Worldwide: TB
Developed: autoimmune (destruction of 21-hydroxylase)
Rarer: metastases, HIV, meningococcal sepsis (causing haemorrhage), amyloid deposits, bilateral adrenalectomy
Investigations for Addison’s
8am cortisol level:
< 100 nmol/L: admit to hospital
100–500 nmol/L: refer for synacthen test, consider admission if symptoms are severe
> 500 nmol/L: Addison’s is unlikely
What is the synacthen test?
250mcg tetracosactide (synacthen) Cortisol measured at 0, 30 and 60 mins
Should be >430 nmol/L
Different adrenal cortex layers and what they produce
Zona glomerulosa - mineralcorticoids
Zona fasciculata - glucocorticoids
Zona reticularis - androgens
What is the adrenal medulla responsible for producing?
Catecholamines (derived from tyrosine)
- dopamine
- adrenaline
- noradrenaline
Cushing’s syndrome signs and symptoms
Head: buffalo hump, facial flush, moon face
Body: hypertension, oedema, muscle wasting, acne, thin skin, striae,
Symptoms: lethargy, weight gain, depression, easy bruising, amenorrhoea, reduced libido
Cushing’s treatment
Medical: metyrapone (11beta-hydroxylase inhibitor - reduces cortisol)
Surgical: transphenoidal pituitary resection, adrenalectomy, ectopic tumour excision
Cushing diagnosis - primary investigations
24 hour urinary cortisol
Midnight cortisol
Low dose dexamethasone
How does cortisol lead to osteopenia?
Inhibits osteoblast activity
Inhibits vitamin D so reduces calcium reabsorption in intestines
Gigantism definition
Excessive GH secretion in childhood before epiphyseal fusion: height >2sd for patient’s age and sex
Where is IGF-1 released from and what effect does it have on GH?
Released from liver
Negative feedback on GH
Stimulates somatostatin (which also is a negative regulator of GH)
Signs and symptoms of acromegaly
Mass effect: visual changes and headaches
Face: enlarged lips and nose, wide spaced teeth, deep skin creases
Body: large hands and feet, hyperpigmentation, aganthosis nigricans
Carpal tunnel syndrome
Increased risk of arrhythmias, hypertension, cardiomyopathy
What cancer are you more at risk of in acromegaly?
Colorectal
Gigantism features?
Mass effect: visual changes and headaches
Face: frontal bossing, coarse facial features
Obesity, tall stature, large hands and feet
Acromegaly investigations
Serum IGF-1
Oral glucose tolerance test: 100g oral glucose, measure GH before and after (should be suppressed below <0.6mcg/L if normal)
MRI pituitary
Acromegaly management
- Surgical (microadenomas more successful, recurrence of all adenomas is 10%)
- Radiotherapy (usually combined with medical therapy, risk of hypopituitarism - avoid if reproductive age)
- Medical therapy:
somatostatin receptor agonists (octreotide) bridge to surgery
dopamine agonist (bromocriptine) shrink tumours
GH antagonists
Effects of growth hormone
Increased lipolysis, protein synthesis and gluconeogenesis
Increased bone mineralisation
IGF-1 release
Causes of carpal tunnel syndrome
Pregnancy Rheumatoid arthritis Acromegaly Glucose Mechanical (e.g. fractures) Amyloid deposits Thyroid underactive Infection Crystals (gout)
T2 diabetic with hypoglycaemia and low GCS - management?
100ml of 20% Glucose IV
Buccal glucose if normal GCS
Features seen in Graves but not other hyperthyroidism causes
Eye disease (exophthalmos, ophthalmoplegia, glaucoma, proptosis)
Thyroid acropachy (soft tissue swelling of hands and feet, clubbing, periostitis)
Pretibial myxoedema (mucopolysacharide deposition)
Initial management of hypercalcaemia
3-4L IV saline
Bisphosphonates
Complications of thyroidectomy
Laryngeal nerve palsy (hoarse voice)
Hypoparathyroidism –> hypocalcaemia (tingling peripheries)
Effects of thyroxine on the body
BMR: increases Basal Metabolic Rate
Heart: increases heart rate and contractility (increases sensitivity to catecholamines)
Growth: increases release and effect of GH and IGF-1
Metabolism: anabolic at low levels, catabolic at high levels
Hyperthyroid causes of thyrotoxicosis
Grave’s
Toxic multinodular goitre
Solitary toxic adenoma
Amiodarone-induced thyrotoxicosis type 1 (increased iodine uptake)
Pituitary adenoma
Beta-HCG (mimics TSH) - pregnancy, hydatidiform mole
Causes of thyrotoxicosis without hyperthyroidism
De Quervain’s (inflammation of thyroid)
Amiodarone-induced thyrotoxicosis type 2 (destructive thyroiditis)
Levothyroxine
Follicular thyroid cancer
Grave’s symptoms
Goitre
Proptosis, lid lag, ophthalmoplegia, dry eyes
Visual loss
Fine tremor
Sweating
Palpitations, tachycardia, arrhythmia, high output cardiac failure
Hyperreflexia
Hyperdefacation, weight loss, increased appetite
Pretibial myxoedema
Oligomenorrhoea, menorrhagia
Grave’s ophthalmopathy classification
No signs or symptoms Only signs Soft tissue involvement Proptosis Extra ocular involvement Corneal involvement Sight loss
SPECS- refer, steroids, irradiation, surgical decompression
Subclinical hyperthyroidism
Low TSH
Normal T4
Radiodine treatment risks
Increased risk of Graves’ eye disease
CI in pregnancy or breastfeeding
Thyrotoxic crisis presentation
Hyperthermia, nausea, vomiting, hypertension, tachycardia, arrhythmias, seizures, cognitive decline
Thyrotoxic crisis management
Beta blockers
Thionamides (propylthiouracil) - antithyroid and blocks T4 conversion to T3
Corticosteroids - blocks T4 to T3 conversion
Dialysis or plasma exchange may be required
What is your treatment of choice for a woman in 1st trimester of pregnancy with thyrotoxicosis
Propylthiouracil (change to carbimazole in 2nd trimester as prop assoc with liver injury)
Dose titration (NOT block and replace)
What are beta blockers in pregnancy associated with?
IUGR
Fetal bradycardia
Neonatal hypoglycaemia
Who can’t you give pioglitazone (thiazolidinediones)?
Someone with heart failure
Which steroid has least mineralocorticoid (fluid-retention) activity and when would you use it?
Dexamethasone (anti-inflammatory)
Raised ICP secondary to brain tumour
First line treatment for diabetic neuropathy?
Amitriptyline. pregabalin, gabapentin, duloxetine
Tramadol as rescue therapy for exacerbations
Capsaicin for localised neuropathic pain
After metformin, what drug would you generally give to a non-obese patient and why? Who would you avoid it in?
Sulfonylurea (gliclazide) as most effective at reducing blood glucose
Avoid if patient need to avoid hypoglycaemia (e.g. professional drivers) as risk of hypoglycaemia
HbA1c target if patient on a drug with hypoglycaemic risk?
53
Which hormones are reduced in the stress response?
Insulin
Oestrogen
Testosterone
Which blood pressure medication is given to patients diagnosed with phaeochromocytoma and why?
Labetalol
Has both beta and alpha blocker mechanism (reduces cardiac output and peripheral vascular resistance)
Why might a patient with long-standing T1 diabetes have reduced hypoglycaemic awareness?
Neuropathy of the autonomic nervous system
Potassium management in patient with DKA
> 5.5: none
3.5-5.5: 40
<3.5: specialist review
Start giving potassium along with IV fluids after first hour
When should you add dextrose to DKA management?
Blood glucose <15mmol/L
When should you add metformin to a T1 diabetic’s management?
BMI >25
Initial management of T1 diabetic
Basal-bolus insulin regimen with twice-daily insulin detemir
Treatment of choice for maturity onset diabetes in the young (with HNF-1 alpha)?
Sulfonylurea (gliclazide)
Causes of gynaecomastia
Testicular failure or cancer (e.g. mumps)
Ectopic tumour secretion
Physiological with puberty
Drugs (spironolactone, digoxin)
Liver disease
Hyperthyroidism
Syndromes with androgen deficiency (Klinefelters, Kallmans)
Management of pituitary incidentaloma?
Lab screening for hormone secretions - is it functional or non-functional??
Indications for surgical removal of pituitary tumour?
Hypersecreting tumour (other than prolactinoma)
Visual disturbance
Pressure on optic nerves or chiasm
Pituitary apoplexy
How many units of insulin in 1ml?
1000
Causes of pseudo Cushings
Alcohol abuse
Depression
What electrolyte is necessary for PTH secretion, and thus what effect will a deficiency of it have on calcium levels?
Magnesium
Low magnesium results in low calcium
Characteristics of benign adenomas?
Lipid-rich core
Well-circumscribed
Diabetes inspidus treatment
Desmopressin
Pituitary apoplexy
Headache and visual field loss
Investigations: bloods, visual fields, MRI and CT
Treatment: hydrocortisone 100mg bolus (followed by 50-100 doses)
Complication of transsphenoidal surgery?
Postoperative diabetes insipidus
Drug causes of hyponatraemia
Omeprazole Sodium valproate, carbamazepine Diuretics/ace-i Desmopressin Sertraline Ecstasy
Medical causes of hyponatraemia?
All organ failures (liver, cardiac, kidney, thyroid, adrenal)
A 19-year-old lady is admitted to ITU with severe meningococcal sepsis. She is on maximal inotropic support and a CT scan of her chest and abdomen is performed. The adrenal glands show evidence of diffuse haemorrhage.
Waterhouse-Friderichsen Syndrome
Which steroid has the most glucocorticoid (anti-inflammatory) activity and least mineralocorticoid (fluid retention)
Dexamethasone
